Derek VanderHorst, Pharm.D., BCPS, BCIDP
Clinical Pharmacy Specialist - Adult Infectious Diseases
On Jan. 1, 2017, The Joint Commission's standards on antimicrobial stewardship for inpatient acute care settings went into effect. Since that time, many institutions have implemented and/or expanded their antimicrobial stewardship efforts. No matter if your antimicrobial stewardship program (ASP) is in its infancy or has existed for years, they all share the same need for high quality data to identify areas for improvement or highlight the impact of the program. The Centers for Disease Control and Prevention (CDC) recommends a variety of metrics that an ASP may use; including antimicrobial purchasing costs, defined daily doses (DDD) and days of therapy (DOT). Quite often the primary metric used by an ASP is selected based on the available resources for your institution; the CDC recommends that if possible, DOT is used as the aforementioned primary metric.1
In addition to metrics that measure antimicrobial utilization, ASPs often include their infection prevention department for assistance with tracking antimicrobial resistance rates over time and healthcare acquired infection rates. Many of the healthcare acquired infections, like healthcare, onset Clostridioides difficile rates, are collected and reported to the National Healthcare Safety Network (NHSN).
In an effort to compile these antimicrobial use and resistance data from across the country, NHSN created the Antimicrobial Use and Resistance (AUR) module for voluntary reporting of DOT, as well as, trends in antimicrobial resistance.2 In Nov. 2018, Spectrum Health Grand Rapids began reporting data to the Antimicrobial Use module of NHSN and shortly after in May 2018 all Spectrum Health hospitals also began contributing data to the NHSN AUR module. With this advancement, our ASP was given the opportunity to significantly improve the quality of data for which we used to measure our program. The NHSN AUR module has a plethora of pre-made reports that can aid stewardship personnel in identifying outlying antimicrobials, measuring trends in usage, and simply determining the most commonly utilized antimicrobials in your institution.2
In addition to these more global, high-level reports, the NHSN AUR Module can quickly provide detailed information on the specific number of calendar days an antimicrobial was administered to a patient for the entire hospital or a particular nursing unit in question. The AUR module can even take these data one step further and report the specific route that a medication was given by providing the data in one of four categories: intravenous, respiratory, digestive and respiratory. All of the above data can then be automatically standardized per 1,000 patient days present so that month to month (or year to year) comparisons can be made. Spectrum Health was able to utilize this data to compare antimicrobial use between similar intensive care units, as well as, identifying areas in our system that were significant outliers in the use of carbapenems.
Another pre-built report offered by the AUR module is the Standardized Antimicrobial Administration Ratio (SAAR) that can be used to measure the antimicrobial utilization of one facility to another. It is similar in concept to the Standardized Infection Ratio (SIR) that is commonly used by our Infection Control departments. While caution should be used when blindly comparing the SAARs of two different institutions, we found it beneficial to compare two similar units within our facility, as well as, identifying outlying areas in our system that had either an excessively high or low SAAR. In addition to the benefit that the SAAR can have for your institution, participating in the AUR module allows you to contribute data to SAAR database that will only strengthen this metric for others as the years go by.
The use of the NHSN AUR module has been our quality metrics significantly more meaningful to not only the ASP personnel, but to our leaders as a whole. The module allows for the creation of digestible graphics that can easily illustrate trends over time and graphs to visually depict percent changes in antimicrobial utilization. Those of us that work in antimicrobial stewardship know that it can be difficult to convey all the complexities that impact our bottom line metrics. The data obtained from the NHSN AUR module has made it much easier for our ASP personnel to tell the story of antimicrobial stewardship within our system. While preparing your institution to report data to the NHSN AUR module can be complex, the return on investment can be well worth it. For specific details on how to begin the process of reporting to NHSN's AUR module, look for Dr. Rand Sulaiman's article in the May 2019 edition of the MSHP Monitor.
Centers for Disease Control and Prevention [Internet]. Atlanta (GA): CDC; c1946-2017. Core Elements of Hospital Antibiotic Stewardship Programs; 2016 May 25 [cited 2017 Jan. 17]; [about 15 screens]. Available from: https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html
Centers for Disease Control and Prevention [Internet]. Atlanta (GA): CDC; c1946-2018. Antimicrobial Use and Resistance Module; 2019 Jan. [cited 2019 Jan. 28]; [about 53 screens]. Available from: https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf